More and more localities and states have stopped waiting for the FDA to get rid of flavored e-cigarettes, including menthol, and enacted local laws or policies ending the sale of flavored e-cigarettes. (Others, led by San Francisco, have banned the sale of all flavored tobacco products.) Fatma Ali and colleagues at the CDC Foundation, CDC Office on Smoking and Health, and Truth Initiative just published “Evaluation of statewide restrictions on sales of e-cigarette sales in the US from 2014 to 2020,” that found big drops in e-cigarette sales in Massachusetts, New York, Rhode Island, and Washington following flavored sales bans (which banned sales of all flavors but tobacco).
They obtained e-cigarette sales using checkout bar code scanner data in these 4 states and compared what happened to 35 other control states that did not have statewide bans. They controlled for time, underlying trends in each state, other state tobacco control policies, demographics, COVID-19, EVALI and other unspecified differences between states (called “state fixed effects” by statisticians). They also did a sensitivity analysis that accounted for cross-border sales.
As shown in the graph above (from their paper):
prohibition of all e-cigarette products in Massachusetts was associated with a 94.38% (95%CI, 93.37%-95.23%) reduction in mean 4-week total e-cigarette unit sales from November 3 to December 1, 2019, compared with the control states. Beginning in December 2019, this policy was narrowed to restrict the sale of non–tobacco-flavored e-cigarettes and was associated with an 88.91% (95%CI, 83.29%-92.64%) reduction in mean 4-week total e-cigarette sales from December 29, 2019, to December 27, 2020, compared with the control states.
In New York, prohibition of non–tobacco-flavored e-cigarette sales was associated with a 30.65% (95%CI, 24.08%-36.66%) reduction in mean 4-week total e-cigarette sales from June 14 to December 27, 2020, compared with the control states. In Rhode Island, prohibition of non–tobacco-flavored e-cigarette sales was associated with a 31.26% (95%CI, 11.94%-46.34%) reduction in mean 4-week total e-cigarette sales from November 3, 2019, to December 27, 2020. Washington’s temporary policy from November 3, 2019, to January 26, 2020, was associated with a 25.01% (95%CI, 18.43%-31.05%) reduction in mean 4-week total e-cigarette sales.
These overall drops occurred even though there were increases in sales of tobacco-flavored e-cigarettes following the bans. In other words, the drop in sales of flavored e-cigs was larger than the compensatory increase in tobacco-flavored e-cigs, resulting in net public health benefit.
Washington state is particularly interesting. In Washington, an executive order prohibiting sale of non–tobacco-flavored e-cigarettes went into effect on October 10, 2019, and lasted for 120 days. During those 120 days, total e-cigarette sales dropped by 25% and tobacco-flavored e-cigarettes had the largest unit sales share (82%-93%) from October 2019 to February 2020. After the ban expired, sales rebounded and menthol-flavored e-cigarettes dominated (30%-51%).
And menthol is a major flavor in the control states that did not have any restrictions (top row in graph above).
The lesson for state and local health policy makers — and FDA: It is important to include menthol in e-cig flavor bans.
Here is the abstract:
Importance: e-Cigarettes are the most commonly used tobacco product among US youths. Flavors are among the most cited reasons for use of e-cigarettes among youths, and therefore, some states have imposed restrictions on flavored e-cigarette sales. To our knowledge, no study has compared e-cigarette sales between states with statewide flavored e-cigarette restrictions and states without such restrictions while controlling for co-occurring events.
Objective: To assess whether implementation of statewide restrictions on flavored e-cigarette sales in Massachusetts, New York, Rhode Island, and Washington was associated with a reduction in total e-cigarette unit sales from 2014 to 2020.
Design, setting, and participants: This cross-sectional study with difference-in-differences analysis used e-cigarette retail sales data from Massachusetts, Rhode Island, and Washington, which implemented restrictions on flavored e-cigarette sales in October 2019; New York, which implemented these restrictions in May 2020; and 35 states without these restrictions (control states). Sales were summed into 4-week periods from August 24, 2014, to December 27, 2020, for a total of 2988 state-period observations.
Main outcomes and measures: A difference-in-differences analysis was conducted to compare e-cigarette unit sales in the 4 states with flavor restrictions (before and after implementation) with those in the 35 control states. The model controlled for other population-based policies and emergent events (eg, the COVID-19 pandemic). Data on 4-week e-cigarette unit sales were sorted into 4 flavor categories (tobacco, menthol, mint, and other). Unit sales were standardized to reflect the most common package sizes for each product type.
Results: Statewide restrictions on non-tobacco-flavored e-cigarette sales were associated with the following reductions in mean 4-week total e-cigarette sales in intervention states compared with control states from October 2019 to December 2020: 30.65% (95% CI, 24.08%-36.66%) in New York, 31.26% (95% CI, 11.94%-46.34%) in Rhode Island, and 25.01% (95% CI, 18.43%-31.05%) in Washington. In Massachusetts, the comprehensive sales prohibition of all e-cigarette products was associated with a 94.38% (95% CI, 93.37%-95.23%) reduction in 4-week sales compared with control states. Except in Massachusetts, where all sales of flavored e-cigarettes decreased, reductions were found only for non-tobacco-flavored e-cigarette sales in the other states with restrictions. Among control states, mean sales decreased by 28.4% from August 2019 to February 2020 but then increased by 49.9% from February through December 2020.
Conclusions and relevance: In this cross-sectional study, statewide restrictions on the sale of flavored e-cigarettes in Massachusetts, New York, Rhode Island, and Washington were associated with a reduction in total e-cigarette sales. These findings suggest that not all e-cigarette users who purchased non-tobacco-flavored e-cigarettes switched to purchasing tobacco-flavored e-cigarettes after policy implementation.
The full citation is: Ali FRM, Vallone D, Seaman EL, Cordova J, Diaz MC, Tynan MA, Trivers KF, King BA. Evaluation of Statewide Restrictions on Flavored e-Cigarette Sales in the US From 2014 to 2020. JAMA Netw Open. 2022 Feb 1;5(2):e2147813. doi: 10.1001/jamanetworkopen.2021.47813. PMID: 35142832. The paper is available for free here.
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